The Children's Hour:

A Life in Child Psychiatry

Kenneth S. Robson, M.D.

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e-Book 2016 International Psychotherapy Institute

From The Children's Hour: A Life in Child Psychiatry by Kenneth S. Robson, M.D.
Copy right 2010 by Kenneth S. Robson, M.D.

All Rights Reserved

Created in the United States of America

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Family Matters
Happy families are all alike; every unhappy family is unhappy in its own way.

-Leo Tolstoy
The family system is not intrinsically benign. Dysfunction is, given the nature of man, inherent in its
structure. It is endowed with enormous power to facilitate but also stunt and sometimes destroy the
forward trajectory of a childs life. In the belly of the family is a child psychiatrists diagnostic and
therapeutic overlook. From this vantage point the possibilities for change are sized up and, when
possible, put in motion. Working knowledge and artful, nuanced skill in shifting the frozen gears of
family systems are major levers for freeing up a childs developmental energies. But layman or
professional, we are all limited by the imprints and echoes of our own families. A colleague of mine in
Boston, a highly respected family therapist, decided to try repairing the damage in his family of origin by
gathering them together in Manhattan where they lived. On the Massachusetts Turnpike, en route to this
event, he fell asleep at the wheel, narrowly avoiding a serious accident. Assuming that Fate was warning
him, he returned home to try again. On his second attempt a similar scenario repeated itself. Wisely
ending this venture, launched in the spirit of physician heal thyself, my colleague, somewhat
sheepishly, acknowledged that in facing his family he was flooded with emotions too powerful to be
contained. How many of us, I have often wondered, could express with candor to our parents and
siblings the accumulated grievances, past and present, of our family life ?
Family has its darker sides. To Alexander Pope it was a commonwealth of malignants; to
Strindberg it was the place where innocent children are tortured...where wills are broken by parental
tyranny, and self-respect smothered by crowded, jostling egos. While we know of and often idealize the
familys power for the good, we sometimes ignore its destructive influences. The truth of family lies,
perhaps, somewhere in between. One of modern psychiatrys great contributions to understanding
human behavior in general, and the development of health and illness in children in particular, is the
creation of a vast amount of observational data on family systems and the laws that govern them. The
original models of family as an interactive system were borrowed from Werner von Brauns
investigations into missiles and rockets, appropriately identifying family with a category of dangerous
explosives. Studies of families have led to family therapies, interventions treating the entire system as
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patient; other research has contributed to an increasingly refined knowledge of the specific contributions
of family processes to the shaping and emergence of psychiatric disorders in childhood and adolescence.
In the last forty years many rich and testable hypotheses have been generated, some directly applicable
to the practice of child psychiatry.
Adelaide Johnson and Stanley Szurek studied the families of children who exhibited anti-social
behaviors, interested in understanding the parental sanctioning of delinquency. Over several years of
observation they formulated their now classical hypothesis that deficiencies of conscience in one or both
parents, what they called superego lacunae (like the holes in Swiss cheese), lead to ambiguous, mixed
communications to the child that are heard as invitations to carry out the very acts simultaneously
discouraged or prohibited. Somehow, the valence of permission to engage in anti-social behavior mutes
or extinguishes the prohibition against it.
An example: the father of a nubile, adolescent daughter, struggling with his own sexual feelings
and aroused by her pubescence, constantly criticizes her boyfriends and is suspicious that she is sexually
involved with them. His distress is articulated with comments to his daughter such as you little slut, or
next thing you know youll be home with a baby. The overt content of these messages is be careful,
control yourself, but the powerful, covert content is a call to action: Go and get pregnant. In a diagnostic
evaluation of my own, I interviewed a six-year-old fire-setter with his mother. She assured me that she
and his father were strict and clear with their son about the danger of matches. In the midst of that
assurance she pulled out a cigarette. As if on command, her son wordlessly plucked the pack of matches
from her hand and, executing an obviously well-practiced ritual, struck and lit one as his mother leaned
over to accept his adeptly delivered assistance.
It happens in the best of families. On a Sunday afternoon I was called by a professors wife, in tears,
desperate to stop her husband from beating their twelve-year-old, honors student son. As we spoke she
held the phone out so that his screams could be heard from the basement where his father had taken him
to receive his punishment. On discovering that fifty dollars was missing from his dresser, her husband
had grabbed the boy, shaken him and accused him of the theft. A forced confession provoked the paternal
rage that I was overhearing. Mother refused, in shame, to call the police. I insisted that she put her
husband on the phone. A furious voice told me to mind my own business. I identified myself as a
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colleague and told him that unless he stopped the assault immediately, I would be obliged to call the
police. A long silence ensued, then a grudging okay. I asked that he, his wife and son come to my office.
He waffled, I insisted.
Their son, Rob, was a slender, athletic boy, tall and handsome, dressed casually in a uniform of the
well-to-do. His face was flushed, bruises evident on his cheeks. His father, whom I greeted with a firm,
respectful handshake that he returned, was a striking man, out of central casting for English gentry. Robs
mother, pale and tearful, was a lady in dress and manner. I met alone with Rob who, despite my
assurance of privacy, took the Fifth Amendment. I invited his parents in. Fill me in, I began. The father
wasted no time: The little bastard stole a wad from me, right under my nose. What, he asked, would
you do if it was your son? I hope not thrash him. In my family thats off limits and it ought to be in yours.
Where, I asked, do you keep your money? As the narrative unfolded it became clear that the top of the
fathers dresser was the family ATM. His change and his folding money lay there, uncounted and
unaccounted for except on rare occasions. Both mother and son availed themselves of these funds on a
regular basis without acknowledgment on their part or protest on the fathers. Occasional paternal
rampages, such as had just transpired, were unconvincing since his banking practices never changed for
more than a day or so. Honesty and integrity, I was assured, were shared family values. Rob was stuck; so
was I. In this silent, persistent scenario, who was the patient? Father, mother, son or family unit? My
mandatory reporting to the Department of Social Services affected only a temporary lull in the pattern of
family cash flow.
The clinical accuracy and predictive power of the Johnson/ Szurek hypothesis is quite remarkable.
When I see patterns of family communication such as just described, I know immediately that delinquent
acts by the children involved (theft, vandalism, sexual promiscuity, firesetting, etc.) are enmeshed in a
family process whose faults are both patently obvious to observers and remarkably obscure, inaccessible
to family members, even when identified. The power of unconscious impulses shared and amplified in a
family system is such that efforts on my part to illuminate, not to mention modify the system, will fall on
deaf ears. In fact, there is little or nothing I can do to alter delinquent behavior despite a birds-eye view
of its causal agents. I hold the lock, know the combination, but cannot open the shackle. The disorders of
conduct bred by dysfunctioning families seem immune to any known psychotherapies. They are a stable
historical presence over many generations. Eve, after all, was not given the apple. She took it. Mans first
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disobedience was not his last.

Salvatore Minuchin and his colleagues came at the family system from another direction. Their
observations suggested that there was a continuum of family interactive styles that, if known, would
predict the diagnostic profiles of the children in any family. The Disengaged family system they
characterized by the isolation of its members from one another, like right and left hands quite unaware of
each others plans. Syndromes of action and impulse, externalizing disorders seem to be associated with
Disengagement: conduct disorders, anti-social personalities, and alcohol or substance abuse In one such
family that I saw in a teaching conference, husband and wife rarely spoke; there were no common
mealtimes, and neither was familiar with the childrens teachers. Sean, the oldest son, nineteen, drugaddicted and unemployed, had not been seen for some weeks by his family. He returned silently to the
family home and hung himself in the basement while life above went on as usual. No one in the family
was aware that Sean was in town, had come home, or was suicidally depressed.
In contrast, the Enmeshed family style described by Minuchin exhibits poor interpersonal
boundaries, little differentiation of one member from another, minimal autonomy in the children, and
little or no privacy. My business is your business. My phone call, conversation, mail and sometimes thoughts
are yours. Here one finds internalizing disorders such as depression, anxiety, psychosis and
psychosomatic syndromes. David, eighteen, returned home after only a month of his first year in college,
having been described as anxious by the college counseling center. His mother called for an emergency
appointment. David was tall, skinny, homely and paranoid. Acutely schizophrenic, he was given antipsychotic medication in my office some hours before he was hospitalized. The next day his mother called
to ask that I meet with her and her husband immediately. The night of Davids admission to inpatient
care, she noticed that his father had suddenly developed the precise throat-clearing mannerism that
David displayed. Based upon this single piece of data, she concluded that her husband was, quite
literally, turning into David, becoming psychotic, and began giving him the remaining doses of the
medication Id prescribed for her son. Psychologically fused with David, unable to tolerate his absence,
she instantly transformed her husband into her missing child to re-establish equilibrium in the family
system. In this family, even with a scorecard, one couldnt know the players.
I have found Minuchins ideas useful but over-simplified. There are few families within which
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enmeshment or disengagement exist in anything approaching pure culture. Most families display some
elements of both.
The ancient warning that those whom the Gods would destroy they first make mad needs
revision in light of family systems theory: those whom families must keep, to maintain the integrity of the
parental relationship, they make mad or, if already impaired, resist repairing. The ill wind of a disturbed
or otherwise chronically ill child often blows one or both parents good. They can unite in a common,
never-ending project, or join forces against an outside enemy, thus distracting them from the bankruptcy
of their marriage and the dissolution of the family. To child psychiatrists this counter-intuitive dynamic is
commonplace. To parents who may become aware that helpfulness to the ill child carries with it the high
stakes of marital dissolution, the insight is unwelcome and alarming. Its cold, fluorescent, truthful glow
often lies buried beneath but at the center of the noise and tumult of a familys life.
Pat was, at twelve, the oldest of three children in an apparently well-knit family. Father, an
attorney, appeared invested in his sons life but never quite followed through with the steps to help Pat
in his failing academic pursuits and social estrangement. Pat was his mothers full-time project.
Chauffeur, tutor and social secretary, she nonetheless complained bitterly about his endless needs and
lack of progress. Seen together, his parents behaved much like Penelope in Homers Odyssey, unraveling
during the night what she had woven earlier that day, moving nowhere with deliberation. From
confusion and uncertainty about how much to supervise Pats errant studies or what his punishments
should be for incomplete work, they moved with me to a concrete plan of action by our sessions end.
When we reconvened two weeks later it was as if no plan had been formulated. They took each other and
me to task for not knowing how to deal with Pats school problems and appeared as confused as before.
The confusion of the parents was not relieved by my but dont you remember?
In their interactions with one another, as we sorted through the confusion, the father waxed
increasingly angry at his wife, scornful of her efforts, which he belittled. Shortly reduced to tears, she
implored her mate to guide her, tell her what to do. I saw that the father was fed up with his spouse; his
dislike was a palpable presence. Sensing his rancor, the mother wept, sank down in her chair, turned
paler. After several cycles of this pattern, I wondered out loud with Pats parents if they might be
struggling with issues of their own, unrelated to Pat but within which he might be caught. My gentle,
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tentative query was met with blank looks. They accepted my referral to a marital counselor but after two
sessions found her schedule, her fees and, most of all, her questions unrelated to Pats difficulties.
While they agreed that every couple could benefit from someone like her, they spoke as one in saying
that their priorities were with Pat. Their son, however, keeper of the family glue, expensive glue,
deteriorated. He was as unreachable to me as were his parents. All began to wonder out loud whether
this therapy stuff was worth the trouble but, with one foot out the door, continued. I knew that my
hands were tied, as were Pats, and tactfully ended my fruitless efforts.
At a more primitive level, Arnie was the first of my patients to instruct me in the (unconscious)
parental motivation to drive a child crazy. A big, burly, unshaven eighteen-year-old with the look of a
homeless person and a scathing sense of humor, he had been hospitalized for many months with
paralyzing obsessional ruminations and accompanying despair. We liked one another, and Arnie knew
that I appreciated his wry, daily commentary on the state of his ward, my sartorial habits, and his family.
In our weekly meetings he would remark, My father is trying to kill me, or My goddamn mother makes
me nuts, certified nuts. Having made and heard similar comments over the years, I initially discounted
Arnies gripes as relatively standard fare. Then I met his parents and listened more astutely to my
patients frightening but credible allegations.
Arnie was the last of four children; his older siblings had all left home and appeared to be
reasonably successful. His father, a small, intense, dapper man, a Mutt to Arnies Jeff, wore a chronic
scowl. In Arnie s presence he praised his sons unsuccessful efforts at autonomy, immediately undoing
his support with comments like Arnie cant fight his way out of a paper bag, or Anyone dressed like
this slob is going nowhere fast, and How did I grow a son like this? I dont think hes mine. All of this
was directed to me but within easy earshot of his son. For me it was painful and infuriating. Arnies
mother, doughty and bland, stood nodding in compliance with her dominating spouse. Arnie had told
me previously, Shes useless. At this moment I had to agree.
In a session with me shortly after this meeting, Arnie described a weekend at home with his
parents. On Sunday his father had parked across the street, a heavily trafficked highway, from the
restaurant where they were dining. His parents crossed quickly, a feat Arnie could never match since he
took two steps back for every one forward as he traveled in his obsessional manner through this world. At
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the moment he garnered enough forward momentum to join them, his father began a series of
commands: Quick, now . . . no, wait . . . step on it . . . Jesus Christ what is the matter with you? . . . look out,
you idiot, dont you see that car . . . you are a hopeless, hopeless fuck-up . . . youll never make it in life. So
rapid, so confusing and so destructive was this coaching that Arnie, enraged and terrified, walked home,
leaving his parents to dine alone.
This was vintage according to Arnie. His fathers public, humiliating diatribe that led to confusion,
fury, and ultimately paralysis and despair was a pattern that he had incorporated wholesale into the few
remaining fragments of a vestigial self and a vertiginous view of the world that left life perpetually
spinning out of control. Later that year Arnie phoned me on a Sunday afternoon. I could not identify the
screaming voice: I cant take it anymore. Please, Dr. Robson, youve got to help me, youve got to stop them
. . . (prolonged, rageful, desperate screaming, closest, perhaps, to that of a bull elephant) . . . I cant take it
anymore. Arnie was in the midst of another interaction with his family. In fact, he could not take any
more and was transferred the next day to the State Hospital where he remained, lifeless, thereafter. I
thought of it as soul murder. According to Dr. Harold Searles, a gifted student of the chronically mentally
ill, a primary motive for creating insanity in a loved one is to ensure his or her constant presence and
prevent the loved one from ever evolving a life or a self, so that the architect of madness might himself
remain whole, and never alone.
Families, more than their individual members, are idealized; it seems somehow easier to
acknowledge and accept the flaws of a mother, father, brother, sister or grandparent than to find fault
with the family itself. Denial seems to thrive better in the plural than the singular. R.D. Laing, a briefly
famous British psychiatrist, took the unpopular position in his studies of chronic schizophrenia that the
family system is inherently destructive to the development of its individual members, that it can maintain
coherence and survive only at the expense of those members, particularly the children. In part, Laing is
right. But Winston Churchill, his fellow countryman, whose own family was a disaster, commented that
It has been said that Democracy is the worst form of government except all those other forms that have
been tried from time to time. Most would agree, especially on rainy days, that the same can be said of
family.
I believe that child and adolescent psychiatrists are biased toward focusing on the omissions or
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commissions of the families we deal with and help. There is a nameless law that trouble is noisier and
more visible than the sound of what is working properly. This was true even in medical school where
illness and bizarre symptoms fascinated us while public health and prevention put us to sleep. But
nothing is more rewarding than seeing a patient regain equilibrium.
Robins mother and step-father wept when they shared with me the events of their five-year-old
daughters short life. When she was three her father was killed in Vietnam. One year later she developed
the symptoms of ulcerative colitis: multiple bloody stools, painful cramping and trips to the emergency
room by ambulance. The hospital was not a refuge either: Robin suffered the indignities of colonoscopies,
intravenous treatments and the jabbing and poking her condition required. Not surprisingly, Robin
developed states of panic and despair that had become another chronic illness by the time I saw her at
five. She had become fearful of the world, had withdrawn from friends, and had lost confidence in
herself. She was miserable.
Robin was a beautiful child. What struck me most was her wide, inviting smile that said, Im ready.
It was so at odds with what her parents had described to me. Like many children who are exposed to
illness early in life, she was verbally precocious. My dad, she said, told me you would help me, Dr.
Robson. Im a mess of trouble but I dont want to be. And she wept.
Robin received a new pink bicycle for her birthday. She refused to ride it, despite the training
wheels in place and despite her parents patient reassurance. There are central metaphors in many
therapies, and the bicycle became a shared symbol for Robin, her parents and me. With my own children
someone (long forgotten) had taught me to use a rolled up beach towel around a childs waist to produce
stability from behind as the child gains confidence in riding alone, first with training wheels, then alone.
Daily throughout her fifth year, mother in the morning, father when he returned from work in the
evening, held Robin upright as she wobbled, beach-toweled, towards competence. Her parents needed
only the slightest shove from me to get their wheels turning. There was protest and dread, but Robin cut a
deal with meif she really wanted to clean up the mess shed have to do the sweeping. I gave her a
wet mop to put in the garage next to her bike to remind her of our contract.
At summers end she gleefully rode on her own just before her sixth birthday. Pride goeth before

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many falls off a two wheeler. But by seven she was an ardent cyclist without training wheels. She and her
step-father made excursions together. Robins success was a family venture and a family gain that set in
motion the latent assets Robin owned. The beach towel, in the right hands, dried her tears and set her on
a steady course of her own. At age twelve, while still on cortico-steroids, Robin entered adolescence
passing her peers on the curves. Her joy was infectious to her family and to me. While her colitis
stabilized, she continued to suffer flare-ups of painful, bloody diarrhea, but the panic diminished. She
surrounded herself with friends and school went well. Robin imagined a career in pediatrics. Her
familys staunch muscle held this child and let her go in a way that was perfectly choreographed. Like
Nureyev holding Fonteyn.

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